Summary Report for FSPSAs Initiated During the Report Period Center: 04
This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start date of service authorization occurs during the report period). This report does not
represent all FSPSAs that overlap the report period. Note that service authorization periods may
range from 1 to 12 months and may vary in intensity from child to child.
FSPSAs starting between: 01-01-22 and 03-31-22 Date of Report: 04-16-22 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1347 FSPSA's found
Services Cpt Code Number of Number of Total Units Total Cost of Avg Fee
Children Records Authorized Auth Services Per Unit Auth
Service Coordination, Class # 01
SCONLY-SCONLY *SERVICE COORDINATION ONLY 36 36 35.028574 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 36 36 35.028574 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 2 0.672222 $32.6000 $48.5000
OCTH -97165 OT EVAL LOW COMPLEXITY 3 3 0.161111 $8.2200 $51.0500
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 0.288889 $14.7500 $51.0500
OCTH -97165TL OT EVAL LOW COMPLEXITY 1 1 0.161111 $8.2200 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 28 28 38.260318 $1953.2000 $51.0500
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 0.166667 $8.5100 $51.0600
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 0.227777 $11.6200 $51.0300
PSTH -97161GT PT EVAL LOW COMPLEXITY 1 1 0.322222 $16.4500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.305556 $15.6000 $51.0600
PSTH -97163 PT EVAL HIGH COMPLEXITY 17 17 5.416669 $276.5300 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 5 5 0.983333 $50.2000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 6 7 1.911111 $97.5600 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 11 12 6.431747 $286.5400 $44.5500
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 4.142857 $217.7900 $52.5700
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Subtotal (Total Children Is Unduplicated) 62 82 59.451590 $2997.8100 $50.4200
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 12 30 7.188892 $359.4600 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 5 6 2.777777 $138.8900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 0.711111 $17.7800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 4 1.622222 $81.1100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 1.355555 $33.8900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 0.511111 $25.5600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 0.466667 $23.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 1.577778 $39.4500 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 4 4 20.714285 $517.8600 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 45 50 355.142853 $8878.5800 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 4 4 22.000000 $1100.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 422 447 3135.999963 $156800.1300 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 53 54 176.142851 $8807.1500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 473 503 3360.699958 $33607.0300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 25 25 149.142857 $10654.7600 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 22 23 161.285710 $9225.5500 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 16 16 104.714285 $7480.8000 $71.4400
PHY -97110HM PT SESSION BY PT ASST 13 14 86.142856 $4923.9300 $57.1600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 1.000000 $456.0000 $456.0000
SENS -V5264 EARMOLD 1 1 1.000000 $18.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 30 33 161.496429 $11537.3100 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 5 5 32.714285 $454.0800 $13.8800
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Subtotal (Total Children Is Unduplicated) 550 1229 7785.407445 $255410.6400 $32.8100
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Total 1347 7879.887609 $258408.4400 $32.7900
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Number of Children (Unduplicated) With at Least One Authorization 578